Healthcare Provider Details

I. General information

NPI: 1346893468
Provider Name (Legal Business Name): JUAN JOSE GONZALEZ BONIFACIO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5162 WHITTIER BLVD
LOS ANGELES CA
90022-3932
US

IV. Provider business mailing address

488 S BURLINGTON AVE
LOS ANGELES CA
90057-3006
US

V. Phone/Fax

Practice location:
  • Phone: 323-510-5920
  • Fax:
Mailing address:
  • Phone: 213-318-1079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA92496
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: